4. It is granted that the disease may be produced and variously

modified by many causes besides contagion, and more especially by

epidemic and endemic influences. But this is not peculiar to the

disease in question. There is no doubt that smallpox is

propagated to a great extent by contagion, yet it goes through

the same records of periodical increase and diminution which have

been remarked in puerperal fever. If the question is asked how we

are to reconcile the great variations in the mortality of

puerperal fever in different seasons and places with the

supposition of contagion, I will answer it by another question

from Mr. Farr's letter to the Registrar-General. He makes the

statement that "FIVE die weekly of smallpox in the metropolis

when the disease is not epidemic," and adds, "The problem for

solution is, Why do the five deaths become 10, 15, 20, 31, 58,

88, weekly, and then progressively fall through the same measured

steps?"

5. I take it for granted that if it can be shown that great

numbers of lives have been and are sacrificed to ignorance or

blindness on this point, no other error of which physicians or

nurses may be occasionally suspected will be alleged in

palliation of this; but that whenever and wherever they can be

shown to carry disease and death instead of health and safety,

the common instincts of humanity will silence every attempt to

explain away their responsibility.

The treatise of Dr. Gordon, of Aberdeen, was published in the

year 1795, being among the earlier special works upon the

disease. A part of his testimony has been occasionally copied

into other works, but his expressions are so clear, his

experience is given with such manly distinctness and

disinterested honesty, that it may be quoted as a model which

might have been often followed with advantage.

"This disease seized such women only as were visited or delivered

by a practitioner, or taken care of by a nurse, who had

previously attended patients affected with the disease."

"I had evident proofs of its infectious nature, and that the

infection was as readily communicated as that of the smallpox or

measles, and operated more speedily than any other infection with

which I am acquainted."

"I had evident proofs that every person who had been with a

patient in the puerperal fever became charged with an atmosphere

of infection, which was communicated to every pregnant woman who

happened to come within its sphere. This is not an assertion, but

a fact, admitting of demonstration, as may be seen by a perusal

of the foregoing table"--referring to a table of seventy-seven

cases, in many of which the channel of propagation was evident.

He adds: "It is a disagreeable declaration for me to mention,

that I myself was the means of carrying the infection to a great

number of women." He then enumerates a number of instances in

which the disease was conveyed by midwives and others to the

neighboring villages, and declares that "these facts fully prove

that the cause of the puerperal fever, of which I treat, was a

specific contagion, or infection, altogether unconnected with a

noxious constitution of the atmosphere."

But his most terrible evidence is given in these words: "I

ARRIVED AT THAT CERTAINTY IN THE MATTER THAT I COULD VENTURE TO

FORETELL WHAT WOMEN WOULD BE AFFECTED WITH THE DISEASE, UPON

HEARING BY WHAT MIDWIFE THEY WERE TO BE DELIVERED, OR BY WHAT

NURSE THEY WERE TO BE ATTENDED, DURING THEIR LYING-IN: AND ALMOST

IN EVERY INSTANCE MY PREDICTION WAS VERIFIED."

Even previously to Gordon, Mr. White, of Manchester, had said: "I

am acquainted with two gentlemen in another town, where the whole

business of midwifery is divided betwixt them, and it is very

remarkable that one of them loses several patients every year of

the puerperal fever, and the other never so much as meets with

the disorder"--a difference which he seems to attribute to their

various modes of treatment. [Footnote: On the Management of

Lying-in Women. p. 120.]

Dr. Armstrong has given a number of instances in his Essay on

Puerperal Fever of the prevalence of the disease among the

patients of a single practitioner. At Sunderland, "in all, forty-

three cases occurred from the 1st of January to the 1st of

October, when the disease ceased; and of this number, forty were

witnessed by Mr. Gregson and his assistant, Mr. Gregory, the

remainder having been separately seen by three accoucheurs."

There is appended to the London edition of this Essay a letter

from Mr. Gregson, in which that gentleman says, in reference to

the great number of cases occurring in his practice, "The cause

of this I cannot pretend fully to explain, but I should be

wanting in common liberality if I were to make any hesitation in

asserting that the disease which appeared in my practice was

highly contagious, and communicable from one puerperal woman to

another." "It is customary among the lower and middle ranks of

people to make frequent personal visits to puerperal women

resident in the same neighborhood, and I have ample evidence for

affirming that the infection of the disease was often carried

about in that manner; and, however painful to my feelings, I must

in candour declare that it is very probable the contagion was

conveyed, in some instances, by myself, though I took every

possible care to prevent such a thing from happening the moment

that I ascertained that the distemper was infectious." Dr.

Armstrong goes on to mention six other instances within his

knowledge, in which the disease had at different times and places

been limited, in the same singular manner, to the practice of

individuals, while it existed scarcely, if at all, among the

patients of others around them. Two of the gentlemen became so

convinced of their conveying the contagion that they withdrew for

a time from practice.

I find a brief notice, in an American journal, of another series

of cases, first mentioned by Mr. Davies, in the "Medical

Repository." This gentleman stated his conviction that the

disease is contagious.

"In the autumn of 1822 he met with twelve cases, while his

medical friends in the neighbourhood did not meet with any, 'or

at least very few.' He could attribute this circumstance to no

other cause than his having been present at the examination after

death, of two cases, some time previous, and of his having

imparted the disease to his patients, notwithstanding every

precaution." [Footnote: Philad. Med. Journal for 1825, p. 408.]

Dr. Gooch says: "It is not uncommon for the greater number of

cases to occur in the practice of one man, whilst the other

practitioners of the neighborhood, who are not more skilful or

more busy, meet with few or none. A practitioner opened the body

of a woman who had died of puerperal fever, and continued to wear

the same clothes. A lady whom he delivered a few days afterwards

was attacked with and died of a similar disease; two more of his

lying-in patients, in rapid succession, met with the same fate;

struck by the thought that he might have carried contagion in his

clothes, he instantly changed them, and met with no more cases of

the kind. [Footnote: A similar anecdote is related by Sir

Benjamin Brodie, of the late Dr. John Clark, Lancet, May 2,

1840.] A woman in the country who was employed as washerwoman and

nurse washed the linen of one who had died of puerperal fever;

the next lying-in patient she nursed died of the same disease; a

third nursed by her met the same fate, till the neighbourhood,

getting afraid of her, ceased to employ her." [Footnote: An

Account of Some of the Most Important Diseases Peculiar to Women,

p. 4].

In the winter of the year 1824, "several instances occurred of

its prevalence among the patients of particular practitioners,

whilst others who were equally busy met with few or none. One

instance of this kind was very remarkable. A general

practitioner, in large midwifery practice, lost so many patients

from puerperal fever that he determined to deliver no more for

some time, but that his partner should attend in his place. This

plan was pursued for one month, during which not a case of the

disease occurred in their practice. The elder practitioner, being

then sufficiently recovered, returned to his practice, but the

first patient he attended was attacked by the disease and died. A

physician who met him in consultation soon afterwards, about a

case of a different kind, and who knew nothing of his misfortune,

asked him whether puerperal fever was at all prevalent in his

neighbourhood, on which he burst into tears, and related the

above circumstances.

"Among the cases which I saw this season in consultation, four

occurred in one month in the practice of one medical man, and all

of them terminated fatally." [Footnote: Gooch, op. cit., p. 71.]

Dr. Ramsbotham asserted, in a lecture at the London Hospital,

that he had known the disease spread through a particular

district, or be confined to the practice of a particular person,

almost every patient being attacked with it, while others had not

a single case. It seemed capable, he thought, of conveyance, not

only by common modes, but through the dress of the attendants

upon the patient. [Footnote: Lond. Med. Gaz., May 2, 1835.]

In a letter to be found in the "London Medical Gazette" for

January, 1840, Mr. Roberton, of Manchester, makes the statement

which I here give in a somewhat condensed form.

A midwife delivered a woman on the 4th of December, 1830, who

died soon after with the symptoms of puerperal fever. In one

month from this date the same midwife delivered thirty women,

residing in different parts of an extensive suburb, of which

number sixteen caught the disease and all died. These were the

only cases which had occurred for a considerable time in

Manchester. The other midwives connected with the same charitable

institution as the woman already mentioned are twenty-five in

number, and deliver, on an average, ninety women a week, or about

three hundred and eighty a month. None of these women had a case

of puerperal fever. "Yet all this time this woman was crossing

the other midwives in every direction, scores of the patients of

the charity being delivered by them in the very same quarters

where her cases of fever were happening."

Mr. Roberton remarks that little more than half the women she

delivered during this month took the fever; that on some days all

escaped, on others only one or more out of three or four; a

circumstance similar to what is seen in other infectious

maladies.

Dr. Blundell says: "Those who have never made the experiment can

have but a faint conception how difficult it is to obtain the

exact truth respecting any occurrence in which feelings and

interests are concerned. Omitting particulars, then, I content

myself with remarking, generally, that from more than one

district I have received accounts of the prevalence of puerperal

fever in the practice of some individuals, while its occurrence

in that of others, in the same neighborhood, was not observed.

Some, as I have been told, have lost ten, twelve, or a greater

number of patients, in scarcely broken succession; like their

evil genius, the puerperal fever has seemed to stalk behind them

wherever they went. Some have deemed it prudent to retire for a

time from practice. In fine, that this fever may occur

spontaneously, I admit; that its infectious nature may be

plausibly disputed, I do not deny; but I add, considerately, that

in my own family I had rather that those I esteemed the most

should be delivered, unaided, in a stable, by the mangerside,

than that they should receive the best help, in the fairest

apartment, but exposed to the vapors of this pitiless disease.

Gossiping friends, wet-nurses, monthly nurses, the practitioner

himself, these are the channels by which, as I suspect, the

infection is principally conveyed." [Footnote: Lect. on

Midwifery, p. 395.]

At a meeting of the Royal Medical and Chirurgical Society Dr.

King. mentioned that some years since a practitioner at Woolwich

lost sixteen patients from puerperal fever in the same year. He

was compelled to give up practice for one or two years, his

business being divided among the neighboring practitioners. No

case of puerperal fever occurred afterwards, neither had any of

the neighboring surgeons any cases of this disease.

At the same meeting Mr. Hutchinson mentioned the occurrence of

three consecutive cases of puerperal fever, followed subsequently

by two others, all in the practice of one accoucheur. [Footnote:

Lancet, May 3, 1840.] Dr. Lee makes the following statement: "In

the last two weeks of September, 1827, five fatal cases of

uterine inflammation came under our observation. All the

individuals so attacked had been attended in labor by the same

midwife, and no example of a febrile or inflammatory disease of a

serious nature occurred during that period among the other

patients of the Westminster General Dispensary, who had been

attended by the other midwives belonging to that institution."

[Footnote: Lond. Cyc. of Pract. Med., art., "Fever, Puerperal"]

The recurrence of long series of cases like those I have cited,

reported by those most interested to disbelieve in contagion,

scattered along through an interval of half a century, might have

been thought sufficient to satisfy the minds of all inquirers

that here was something more than a singular coincidence. But if,

on a more extended observation, it should be found that the same

ominous groups of cases clusterings about individual

practitioners were observed in a remote country, at different

times, and in widely separated regions, it would seem incredible

that any should be found too prejudiced or indolent to accept the

solemn truth knelled into their ears by the funeral bells from

both sides of the ocean--the plain conclusion that the physician

and the disease entered, hand in hand, into the chamber of the

unsuspecting patient.

That such series of cases have been observed in this country, and

in this neighborhood, I proceed to show.

In Dr. Francis's "Notes to Denman's Midwifery" a passage is cited

from Dr. Hosack in which he refers to certain puerperal cases

which proved fatal to several lying-in women, and in some of

which the disease was supposed to be conveyed by the accoucheurs

themselves. [Footnote: Denman's Midwifery, p. 673, third Am. ed.]

A writer in the "New York Medical and Physical Journal" for

October, 1829, in speaking of the occurrence of puerperal fever

confined to one man's practice, remarks: "We have known cases of

this kind occur, though rarely, in New York."

I mention these little hints about the occurrence of such cases

partly because they are the first I have met with in American

medical literature, but more especially because they serve to

remind us that behind the fearful array of published facts there

lies a dark list of similar events, unwritten in the records of

science, but long remembered by many a desolated fireside.

Certainly nothing can be more open and explicit than the account

given by Dr. Peirson, of Salem, of the cases seen by him. In the

first nineteen days of January, 1829, he had five consecutive

cases of puerperal fever, every patient he attended being

attacked, and the three first cases proving fatal. In March of

the same year he had two moderate cases, in June, another case,

and in July, another, which proved fatal. "Up to this period," he

remarks, "I am not informed that a single case had occurred in

the practice of any other physician. Since that period I have had

no fatal case in my practice, although I have had several

dangerous cases. I have attended in all twenty cases of this

disease, of which four have been fatal. I am not aware that there

has been any other case in the town of distinct puerperal

peritonitis, although I am willing to admit my information may be

very defective on this point. I have been told of some 'mixed

cases,' and 'morbid affections after delivery.'" [Footnote:

Remarks on Puerperal Fever, pp. 12 and 13.]

In the "Quarterly Summary of the Transactions of the College of

Physicians of Philadelphia" [Footnote: For May, June, and July,

1842.] may be found some most extraordinary developments

respecting a series of cases occurring in the practice of a

member of that body.

Dr. Condie called the attention of the Society to the prevalence,

at the present time, of puerperal fever of a peculiarly insidious

and malignant character. "In the practice of one gentleman

extensively engaged as an obstetrician nearly every female he has

attended in confinement, during several weeks past, within the

above limits" (the southern sections and neighboring districts),

"had been attacked by the fever."

"An important query presents itself, the doctor observed, in

reference to the particular form of fever now prevalent. Is it,

namely, capable of being propagated by contagion, and is a

physician who has been in attendance upon a case of the disease

warranted in continuing, without interruption, his practice as an

obstetrician? Dr. C., although not a believer in the contagious

character of many of those affections generally supposed to be

propagated in this manner, has, nevertheless, become convinced by

the facts that have fallen under his notice that the puerperal

fever now prevailing is capable of being communicated by

contagion. How, otherwise, can be explained the very curious

circumstance of the disease in one district being exclusively

confined to the practice of a single physician, a Fellow of this

College, extensively engaged in obstetrical practice, while no

instance of the disease has occurred in the patients under the

care of any other accoucheur practising within the same district;

scarcely a female that has been delivered for weeks past has

escaped an attack?"

Dr. Rutter, the practitioner referred to, "observed that, after

the occurrence of a number of cases of the disease in his

practice, he had left the city and remained absent for a week,

but, on returning, no article of clothing he then wore having

been used by him before, one of the very first cases of

parturition he attended was followed by an attack of the fever

and terminated fatally; he cannot readily, therefore, believe in

the transmission of the disease from female to female in the

person or clothes of the physician."

The meeting at which these remarks were made was held on the 3d

of May, 1842. In a letter dated December 20, 1842, addressed to

Dr. Meigs, and to be found in the "Medical Examiner," [Footnote:

For January 21, 1843.] he speaks of "those horrible cases of

puerperal fever, some of which you did me the favor to see with

me during the past summer," and talks of his experience in the

disease, "now numbering nearly seventy cases, all of which have

occurred within less than a twelve-month past."

And Dr. Meigs asserts, on the same page, "Indeed, I believe that

his practice in that department of the profession was greater

than that of any other gentleman, which was probably the cause of

his seeing a greater number of the cases." This from a professor

of midwifery, who some time ago assured a gentleman whom he met

in consultation that the night on which they met was the

eighteenth in succession that he himself had been summoned from

his repose, [Footnote: Medical Examiner for December 10, 1842.]

seems hardly satisfactory.

I must call the attention of the inquirer most particularly to

the Quarterly Report above referred to, and the letters of Dr.

Meigs and Dr. Rutter, to be found in the "Medical Examiner."

Whatever impression they may produce upon his mind, I trust they

will at least convince him that there is some reason for looking

into this apparently uninviting subject.

At a meeting of the College of Physicians just mentioned Dr.

Warrington stated that a few days after assisting at an autopsy

of puerperal peritonitis, in which he laded out the contents of

the abdominal cavity with his hands, he was called upon to

deliver three women in rapid succession. All of these women were

attacked with different forms of what is commonly called

puerperal fever. Soon after these he saw two other patients, both

on the same day, with the same disease. Of these five patients,

two died.

At the same meeting Dr. West mentioned a fact related to him by

Dr. Samuel Jackson, of Northumberland. Seven females, delivered

by Dr. Jackson in rapid succession, while practising in

Northumberland County, were all attacked with puerperal fever,

and five of them died. "Women," he said, "who had expected me to

attend upon them, now becoming alarmed, removed out of my reach,

and others sent for a physician residing several miles distant.

These women, as well as those attended by midwives, all did well;

nor did we hear of any deaths in child-bed within a radius of

fifty miles, excepting two, and these I afterwards ascertained to

have been caused by other diseases." He underwent, as he thought,

a thorough purification, and still his next patient was attacked

with the disease and died. He was led to suspect that the

contagion might have been carried in the gloves which he had worn

in attendance upon the previous cases. Two months or more after

this he had two other cases. He could find nothing to account for

these unless it were the instruments for giving enemata, which

had been used in two of the former cases and were employed by

these patients. When the first case occurred, he was attending

and dressing a limb extensively mortified from erysipelas, and

went immediately to the accouchement with his clothes and gloves

most thoroughly imbued with its effluvia. And here I may mention

that this very Dr. Samael Jackson, of Northumberland, is one of

Dr. Dewees's authorities against contagion.

The three following statements are now for the first time given

to the public. All of the cases referred to occurred within this

State, and two of the three series in Boston and its immediate

vicinity.

I. The first is a series of cases which took place during the

last spring in a town at some distance from this neighborhood. A

physician of that town, Dr. C, Had the following consecutive

cases:

No. 1, delivered March 20, died March 24.

" 2, " April 9, " April 14.

" 3, " " 10, " " 14.

" 4, " " 11, " " 18.

" 5, " " 27, " May 3.

" 6, " " 28, had some symptoms, recovered.

" 7, " May 8, had some symptoms, also recovered.

These were the only cases attended by this physician during the

period referred to, "They were all attended by him until their

termination, with the exception of the patient No. 6, who fell

into the hands of another physician on the 2d of May." (Dr. C.

left town for a few days at this time.) Dr. C. attended cases

immediately before and after the above-named periods, none of

which, however, presented any peculiar symptoms of the disease.

About the 1st of July he attended another patient in a

neighboring village, who died two or three days after delivery.

The first patient, it is stated, was delivered on the 20th of

March. "On the 19th Dr. C. made the autopsy of a man who had died

suddenly, sick only forty-eight hours; had oedema of the thigh

and gangrene extending from a little above the ankle into the

cavity of the abdomen." Dr. C. wounded himself very slightly in

the right hand during the autopsy. The hand was quite painful the

night following, during his attendance on the patient No. 1. He

did not see this patient after the 20th, being confined to the

house, and very sick from the wound just mentioned, from this

time until the 3d of April.

Several cases of erysipelas occurred in the house where the

autopsy mentioned above took place, soon after the examination.

There were also many cases of erysipelas in town at the time of

the fatal puerperal cases which have been mentioned.

The nurse who laid out the body of the patient No. 3 was taken on

the evening of the same day with sore throat and erysipelas, and

died in ten days from the first attack.

The nurse who laid out the body of the patient No. 4 was taken on

the day following with symptoms like those of this patient, and

died in a week, without any external marks of erysipelas.

"No other cases of similar character with those of Dr. C.

occurred in the practice of any of the physicians in the town or

vicinity at the time. Deaths following confinement have occurred

in the practice of other physicians during the past year, but

they were not cases of puerperal fever. No post-mortem

examinations were held in any of these puerperal cases."

Some additional statements in this letter are deserving of

insertion:

"A physician attended a woman in the immediate neighborhood of

the cases numbered 2, 3, and 4. This patient was confined the

morning of March 1st, and died on the night of Match 7th. It is

doubtful whether this should be considered a case of puerperal

fever. She had suffered from canker, indigestion, and diarrhoea

for a year previous to her delivery. Her complaints were much

aggravated for two or three months previous to delivery; she had

become greatly emaciated, and weakened to such an extent that it

had not been expected that she would long survive her

confinement, if indeed she reached that period. Her labor was

easy enough; she flowed a good deal, seemed exceedingly

prostrated, had ringing in her ears, and other symptoms of

exhaustion; the pulse was quick and small. On the second and

third day there was some tenderness and tumefaction of the

abdomen, which increased somewhat on the fourth and fifth. He had

cases in midwifery before and after this, which presented nothing

peculiar.

It is also mentioned in the same letter that another physician

had a case during the last summer and another last fall, both of

which recovered.

Another gentleman reports a case last December, a second case

five weeks, and another three weeks, since. All these recovered,

A case also occurred very recently in the practice of a physician

in the village where the eighth patient of Dr. C. resides, which

proved fatal "This patient had some patches of erysipelas on the

legs and arms. The same physician has delivered three cases

since, which have all done well. There have been no other cases

in this town or its vicinity recently. There have been some few

cases of erysipelas." It deserves notice that the partner of Dr.

C, who attended the autopsy of the man above mentioned and took

an active part in it, who also suffered very slightly from a

prick under the thumb-nail received during the examination, had

twelve cases of midwifery between March 26th and April 12th, all

of which did well, and presented no peculiar symptoms. It should

also be stated that during these seventeen days he was in

attendance on all the cases of erysipelas in the house where the

autopsy had been performed. I owe these facts to the prompt

kindness of a gentleman whose intelligence and character are

sufficient guaranty for their accuracy.

The two following letters were addressed to my friend Dr. Storer

by the gentleman in whose practice the cases of puerperal fever

occurred. His name renders it unnecessary to refer more

particularly to these gentlemen, who on their part have

manifested the most perfect freedom and courtesy in affording

these accounts of their painful experience.

"January 38, 1843.

II ... "The time to which you allude was in 1830. The first case

was in February, during a very cold time. She was confined the

4th, and died the 12th. Between the 10th and 28th of this month I

attended six women in labor, all of whom did well except the

last, as also two who were confined March 1st and 5th. Mrs. E.,

confined February 28th, sickened, and died March 8th. The next

day, 9th, I inspected the body, and the night after attended a

lady, Mrs. B., who sickened, and died 16th. The 10th, I attended

another, Mrs. G., who sickened, but recovered. March 16th I went

from Mrs. G.'s room to attend a Mrs. H., who sickened, and died

21st. The 17th, I inspected Mrs. B. On the 19th, I went directly

from Mrs. H.'s room to attend another lady, Mrs. G., who also

sickened, and died 22d. While Mrs. B. was sick, on 15th, I went

directly from her room a few rods, and attended another woman,

who was not sick. Up to 20th of this month I wore the same

clothes. I now refused to attend any labor, and did not till

April 21st, when, having thoroughly cleansed myself, I resumed my

practice, and had no more puerperal fever.

"The cases were not confined to a narrow space. The two nearest

were half a mile from each other, and half that distance from my

residence. The others were from two to three miles apart, and

nearly that distance from my residence. There were no other cases

in their immediate vicinity which came to my knowledge. The

general health of all the women was pretty good, and all the

labors as good as common, except the first. This woman, in

consequence of my not arriving in season, and the child being

half-born at some time before I arrived, was very much exposed to

the cold at the time of confinement, and afterwards, being

confined in a very open, cold room. Of the six cases, you

perceive only one recovered.

"In the winter of 1817 two of my patients had puerperal fever,

one very badly, the other not so badly. Both recovered. One other

had swelled leg or phlegmasia dolens, and one or two others did

not recover as well as usual.

"In the summer of 1835 another disastrous period occurred in my

practice. July 1st I attended a lady in labor, who was afterwards

quite ill and feverish; but at the time I did not consider her

case a decided puerperal fever. On the 8th I attended one who did

well. On the 12th, one who was seriously sick. This was also an

equivocal case, apparently arising from constipation and

irritation of the rectum. These women were ten miles apart and

five from my residence. On 15th and 2Oth two who did well. On

25th I attended another. This was a severe labor, and followed by

unequivocal puerperal fever, or peritonitis. She recovered.

August 2nd and 3rd, in about twenty-four hours, I attended four

persons. Two of them did very well; one was attacked with some of

the common symptoms, which, however, subsided in a day or two,

and the other had decided puerperal fever, but recovered. This

woman resided five miles from me. Up to this time I wore the same

coat. All my other clothes had frequently been changed. On 6th, I

attended two women, one of whom was not sick at all; but the

other, Mrs. L., was afterwards taken ill. On 10th, I attended a

lady, who did very well. I had previously changed all my clothes,

and had no garment on which had been in a puerperal room. On

12th, I was called to Mrs. S., in labor. While she was ill, I

left her to visit Mrs. L., one of the ladies who was confined on

6th. Mrs. L. had been more unwell than usual, but I had not

considered her case anything more than common till this visit. I

had on a surtout at this visit, which, on my return to Mrs. S., I

left in another room. Mrs. S. was delivered on 13th with forceps.

These women both died of decided puerperal fever.

"While I attended these women in their fevers I changed my

clothes, and washed my hands in a solution of chloride of lime

after each visit. I attended seven women in labor during this

period, all of whom recovered without sickness.

"In my practice I have had several single cases of puerperal

fever, some of whom have died and some have recovered. Until the

year 1830 I had no suspicion that the disease could be

communicated from one patient to another by a nurse or midwife;

but I now think the foregoing facts strongly favor that idea. I

was so much convinced of this fact that I adopted the plan before

related.

"I believe my own health was as good as usual at each of the

above periods. I have no recollection to the contrary.

"I believe I have answered all your questions. I have been more

particular on some points perhaps than necessary; but I thought

you could form your own opinion better than to take mine. In 1830

I wrote to Dr. Channing a more particular statement of my cases.

If I have not answered your questions sufficiently, perhaps Dr.

C. may have my letter to him, and you can find your answer

there." [Footnote: In a letter to myself this gentleman also

stated," I do not recollect that there was any erysipelas or any

other disease particularly prevalent at the time."]

"Boston, February 3, 1843.

III. "My Dear Sir: I received a note from you last evening

requesting me to answer certain questions therein proposed,

touching the cases of puerperal fever which came under my

observation the past summer. It gives me pleasure to comply with

your request, so far as it is in my power so to do, but, owing to

the hurry in preparing for a journey, the notes of the cases I

had then taken were lost or mislaid. The principal facts,

however, are too vivid upon my recollection to be soon forgotten.

I think, therefore, that I shall be able to give you all the

information you may require.

"All the cases that occurred in my practice took place between

the 7th of May and the 17th of June, 1842.

They were not confined to any particular part of the city. The

first two cases were patients residing at the South End, the next

was at the extreme North End, one living in Sea Street and the

other in Roxbury. The following is the order in which they

occurred:

"CASE 1.--Mrs.-- was confined on the 7th of May, at 5 o'clock, P.

M., after a natural labor of six hours. At 12 o'clock at night,

on the 9th (thirty-one hours after confinement), she was taken

with severe chill, previous to which she was as comfortable as

women usually are under the circumstances. She died on the 10th.

"CASE 2.--Mrs.-- was confined on the 10th of June (four weeks

after Mrs. C), at 11 A. M., after a natural, but somewhat severe,

labor of five hours. At 7 o'clock, on the morning of the 11th,

she had a chill. Died on the 12th.

"CASE 3.--Mrs.--, confined on the 14th of June, was comfortable

until the 18th, when symptoms of puerperal fever were manifest.

She died on the 20th.

"CASE 4.--Mrs.--, confined June 17th, at 5 o'clock, A. M., was

doing well until the morning of the 19th. She died on the evening

of the 21st.

"CASE 5.--Mrs.--was confined with her FIFTH child on the 17th of

June, at 6 o'clock in the evening. This patient had been attacked

with puerperal fever, at three of her previous confinements, but

the disease yielded to depletion and other remedies without

difficulty. This time, I regret to say, I was not so fortunate.

She was not attacked, as were the other patients, with a chill,

but complained of extreme pain in the abdomen, and tenderness on

pressure, almost from the moment of her confinement. In this, as

in the other cases, the disease resisted all remedies, and she

died in great distress on the 22d of the same month. Owing to the

extreme heat of the season and my own indisposition, none of the

subjects were examined after death. Dr. Channing, who was in

attendance with me on the three last cases, proposed to have a

post-mortem examination of the subject of case No. 5, but from

some cause which I do not now recollect it was not obtained.

"You wish to know whether I wore the same clothes when attending

the different cases. I cannot positively say, but I should think

I did not, as the weather became warmer after, the first two

cases; I therefore think it probable that I made a change of at

least a PART of my dress. I have had no other case of puerperal

fever in my own practice for three years, save those above

related, and I do not remember to have lost a patient before with

this disease. While absent, last July, I visited two patients

sick with puerperal fever, with a friend of mine in the country.

Both of them recovered.

"The cases that I have recorded were not confined to any

particular constitution or temperament, but it seized upon the

strong and the weak, the old and the young--one being over forty

years, and the youngest under eighteen years of age... If the

disease is of an erysipelatous nature, as many suppose,

contagionists may perhaps find some ground for their belief in

the fact that, for two weeks previous to my first case of

puerperal fever, I had been attending a severe case of

erysipelas, and the infection may have been conveyed through me

to the patient; but, on the other hand, why is not this the case

with other physicians, or with the same physician at all times,

for since my return from the country I have had a more inveterate

case of erysipelas than ever before, and no difficulty whatever

has attended any of my midwifery cases?"

I am assured, on unquestionable authority, that "about three

years since a gentleman in extensive midwifery business, in a

neighboring State, lost in the course of a few weeks eight

patients in child-bed, seven of them being undoubted cases of

puerperal fever. No other physician of the town lost a single

patient of this disease during the same period." And from what I

have heard in conversation with some of our most experienced

practitioners, I am inclined to think many cases of the kind

might be brought to light by extensive inquiry.

This long catalogue of melancholy histories assumes a still

darker aspect when we remember how kindly nature deals with the

parturient female, when she is not immersed in the virulent

atmosphere of an impure lying-in hospital, or poisoned in her

chamber by the unsuspected breath of contagion. From all causes

together not more than four deaths in a thousand births and

miscarriages happened in England and Wales during the period

embraced by the first Report of the Registrar-General. [Footnote:

First Report, p. 105.] In the second Report the mortality was

shown to be about five in one thousand. [Footnote: Second Report,

p. 73.] In the Dublin Lying-in Hospital, during the seven years

of Dr. Collins's mastership, there was one case of puerperal

fever to 178 deliveries, or less than six to the thousand, and

one death from this disease in 278 cases, or between three and

four to the thousand. [Footnote: Collins's Treatise on Midwifery,

p. 228, etc.] Yet during this period the disease was endemic in

the hospital, and might have gone on to rival the horrors of the

pestilence of the Maternite, had not the poison been destroyed by

a thorough purification.

In private practice, leaving out of view the cases that are to be

ascribed to the self-acting system of propagation, it would seem

that the disease must be far from common. Mr. White, of

Manchester, says: "Out of the whole number of lying-in patients

whom I have delivered (and I may safely call it a great one), I

have never lost one, nor to the best of my recollection has one

been greatly endangered, by the puerperal, miliary, low nervous,

putrid malignant, or milk fever." [Footnote: Op. cit., p. 115.]

Dr. Joseph Clarke informed Dr. Collins that in the course of

FORTY-FIVE years' most extensive practice he lost but FOUR

patients from this disease. [Footnote: Op. cit., p.228.] One of

the most eminent practitioners of Glasgow who has been engaged in

very extensive practice for upwards of a quarter of a century

testifies that he never saw more than twelve cases of real

puerperal fever. [Footnote: Lancet, May 4, 1833.]

I have myself been told by two gentlemen practicing in this city,

and having for many years a large midwifery business, that they

had neither of them lost a patient from this disease, and by one

of them that he had only seen it in consultation with other

physicians. In five hundred cases of midwifery, of which Dr.

Storer has given an abstract in the first number of this journal,

there was only one instance of fatal puerperal peritonitis.

In the view of these facts it does appear a singular coincidence

that one man or woman should have ten, twenty, thirty, or seventy

cases of this rare disease following his or her footsteps with

the keenness of a beagle, through the streets and lanes of a

crowded city, while the scores that cross the same paths on the

same errands know it only by name. It is a series of similar

coincidences which has led us to consider the dagger, the musket,

and certain innocent-looking white powders as having some little

claim to be regarded as dangerous. It is the practical

inattention to similar coincidences which has given rise to the

unpleasant but often necessary documents called INDICTMENTS,

which has sharpened a form of the cephalotome sometimes employed

in the case of adults, and adjusted that modification of the

fillet which delivers the world of those who happen to be too

much in the way while such striking coincidences are taking

place.

I shall now mention a few instances in which the disease appears

to have been conveyed by the process of direct inoculation.

Dr. Campbell, of Edinburgh, states that in October, 1821, he

assisted at the post-mortem examination of a patient who died

with puerperal fever. He carried the pelvic viscera in his pocket

to the class-room. The same evening he attended a woman in labor

without previously changing his clothes; this patient died. The

next morning he delivered a woman with the forceps; she died

also, and of many others who were seized with the disease within

a few weeks, three shared the same fate in succession.

In June, 1823, he assisted some of his pupils at the autopsy of a

case of puerperal fever. He was unable to wash his hands with

proper care, for want of the necessary accommodations. On getting

home he found that two patients required his assistance. He went

without further ablution or changing his clothes; both these

patients died with puerperal fever. [Footnote: Lond. Med.

Gazette, December 10, 1831.] This same Dr. Campbell is one of Dr.

Churchill's authorities against contagion.

Mr. Roberton says that in one instance within his knowledge a

practitioner passed the catheter for a patient with puerperal

fever late in the evening; the same night he attended a lady who

had the symptoms of the disease on the second day. In another

instance a surgeon was called while in the act of inspecting the

body of a woman who had died of this fever, to attend a labor;

within forty-eight hours this patient was seized with the fever

[Footnote: Ibid. for January 1832].

On the 16th of March, 1831, a medical practitioner examined the

body of a woman who had died a few days after delivery, from

puerperal peritonitis. On the evening of the 17th he delivered a

patient, who was seized with puerperal fever on the 19th, and

died on the 24th. Between this period and the 6th of April the

same practitioner attended two other patients, both of whom were

attacked with the same disease and died. [Footnote: London Cyc.

of Pract. Med., art., "Fever, Puerperal."]

In the autumn of 1829 a physician was present at the examination

of a case of puerperal fever, dissected out the organs, and

assisted in sewing up the body. He had scarcely reached home when

he was summoned to attend a young lady in labor. In sixteen hours

she was attacked with the symptoms of puerperal fever, and

narrowly escaped with her life. [Footnote: Ibid.]

In December, 1830, a midwife, who had attended two fatal cases of

puerperal fever at the British Lying-in Hospital, examined a

patient who had just been admitted, to ascertain if labor had

commenced. This patient remained two days in the expectation that

labor would come on, when she returned home and was then suddenly

taken in labor and delivered before she could set out for the

hospital. She went on favorably for two days, and was then taken

with puerperal fever and died in thirty-six hours. [Footnote:

Ibid.]

A young practitioner, contrary to advice, examined the body of a

patient who had died from puerperal fever; there was no epidemic

at the time; the case appeared to be purely sporadic. He

delivered three other women shortly afterwards; they all died

with puerperal fever, the symptoms of which broke out very soon

after labor. The patients of his colleague did well, except one,

where he assisted to remove some coagula from the uterus; she was

attacked in the same manner as those whom he had attended, and

died also." The writer in the "British and Foreign Medical

Review," from whom I quote this statement,--and who is no other

than Dr. Rigby,--adds: "We trust that this fact alone will

forever silence such doubts, and stamp the well-merited epithet

of 'criminal,' as above quoted, upon such attempts [Footnote:

Brit. and For. Medical Review for January, 1842, p. 112.]

From the cases given by Mr. Ingleby I select the following: Two

gentlemen, after having been engaged in conducting the post-

mortem examination of a case of puerperal fever, went in the same

dress, each respectively, to a case of midwifery. "The one

patient was seized with the rigor about thirty hours afterwards.

The other patient was seized with a rigor the third morning after

delivery. ONE RECOVERED, ONE DIED." [Footnote: Edin. Med. and

Surg. Journal, April 1838.] One of these same gentlemen attended

another woman in the same clothes two days after the autopsy

referred to. "The rigor did not take place until the evening of

the fifth day from the first visit. RESULT FATAL." These cases

belonged to a series of seven, the first of which was thought to

have originated in a case of erysipelas. "Several cases of a mild

character followed the foregoing seven, and their nature being

now most unequivocal, my friend declined visiting all midwifery

cases for a time, and there was no recurrence of the disease."

These cases occurred in 1833. Five of them proved fatal. Mr.

Ingleby gives another series of seven cases which occurred to a

practitioner in 1836, the first of which was also attributed to

his having opened several erysipelatous abscesses a short time

previously.

I need not refer to the case lately read before this society, in

which a physician went, soon after performing an autopsy of a

case of puerperal fever, to a woman in labor, who was seized with

the same disease and perished. The forfeit of that error has been

already paid.

At a meeting of the Medical and Chirurgical Society before

referred to, Dr. Merriman related an instance occurring in his

own practice, which excites a reasonable suspicion that two lives

were sacrificed to a still less dangerous experiment. He was at

the examination of a case of puerperal fever at two o'clock in

the afternoon. HE TOOK CARE NOT TO TOUCH THE BODY. At nine

o'clock the same evening he attended a woman in labor; she was so

nearly delivered that he had scarcely anything to do. The next

morning she had severe rigors, and in forty-eight hours she was a

corpse. Her infant had erysipelas and died in two days.

[Footnote: Lancet, May 2, 1840.]

In connection with the facts which have been stated it seems

proper to allude to the dangerous and often fatal effects which

have followed from wounds received in the post-mortem examination

of patients who have died of puerperal fever. The fact that such

wounds are attended with peculiar risk has been long noticed. I

find that Chaussier was in the habit of cautioning his students

against the danger to which they were exposed in these

dissections. [Footnote: Stein, L'Art d'Accoucher, 1794; Dict. des

Sciences Medicales, art., "Puerperal."] The head pharmacien of

the Hotel Dieu, in his analysis of the fluid effused in puerperal

peritonitis, says that practitioners are convinced of its

deleterious qualities, and that it is very dangerous to apply it

to the denuded skin. [Footnote: Journal de Pharmacie, January

1836.] Sir Benjamin Brodie speaks of it as being well known that

the inoculation of lymph or pus from the peritoneum of a

puerperal patient is often attended with dangerous and even fatal

symptoms. Three cases in confirmation of this statement, two of

them fatal, have been reported to this society within a few

months.

Of about fifty cases of injuries of this kind, of various degrees

of severity, which I have collected from different sources, at

least twelve were instances of infection from puerperal

peritonitis. Some of the others are so stated as to render it

probable that they may have been of the same nature. Five other

cases were of peritoneal inflammation; three in males. Three were

what was called enteritis, in one instance complicated with

erysipelas; but it is well known that this term has been often

used to signify inflammation of the peritoneum covering the

intestines. On the other hand, no case of typhus or typhoid fever

is mentioned as giving rise to dangerous consequences, with the

exception of the single instance of an undertaker mentioned by

Mr. Travers, who seems to have been poisoned by a fluid which

exuded from the body. The other accidents were produced by

dissection, or some other mode of contact with bodies of patients

who had died of various affections. They also differed much in

severity, the cases of puerperal origin being among the most

formidable and fatal. Now a moment's reflection will show that

the number of cases of serious consequences ensuing from the

dissection of the bodies of those who had perished of puerperal

fever is so vastly disproportioned to the relatively small number

of autopsies made in this complaint as compared with typhus or

pneumonia (from which last disease not one case of poisoning

happened), and still more from all diseases put together, that the

conclusion is irresistible that a most fearful morbid poison is

often generated in the course of this disease. Whether or not it

is sui generis confined to this disease, or produced in some

others, as, for instance, erysipelas, I need not stop to inquire.

In connection with this may be taken the following statement of

Dr. Rigby: "That the discharges from a patient under puerperal

fever are in the highest degree contagious we have abundant

evidence in the history of lying-in hospitals. The puerperal

abscesses are also contagious, and may be communicated to healthy

lying-in women by washing with the same sponge; this fact has

been repeatedly proved in the Vienna Hospital; but they are

equally communicable to women not pregnant; on more than one

occasion the women engaged in washing the soiled bed-linen of the

General Lying-in Hospital have been attacked with abscesses in

the fingers or hands, attended with rapidly spreading

inflammation of the cellular tissue."[Footnote: System of

Midwifery, p. 292]

Now add to all this the undisputed fact that within the walls of

lying-in hospitals there is often generated a miasm, palpable as

the chlorine used to destroy it, tenacious so as in some cases

almost to defy extirpation, deadly in some institutions as the

plague; which has killed women in a private hospital of London so

fast that they were buried two in one coffin to conceal its

horrors; which enabled Tonnelle to record two hundred and twenty-

two autopsies at the Maternite of Paris; which has led Dr. Lee to

express his deliberate conviction that the loss of life

occasioned by these institutions completely defeats the objects

of their founders; and out of this train of cumulative evidence,

the multiplied groups of cases clustering about individuals, the

deadly results of autopsies, the inoculation by fluids from the

living patient, the murderous poison of hospitals--does there not

result a conclusion that laughs all sophistry to scorn, and

renders all argument an insult?

I have had occasion to mention some instances in which there was

an apparent relation between puerperal fever and erysipelas. The

length to which this paper has extended does not allow me to

enter into the consideration of this most important subject. I

will only say that the evidence appears to me altogether

satisfactory that some most fatal series of puerperal fever have

been produced by an infection originating in the matter or

effluvia of erysipelas. In evidence of some connection between

the two diseases, I need not go back to the older authors, as

Pouteau or Gordon, but will content myself with giving the

following references, with their dates; from which it will be

seen that the testimony has been constantly coming before the

profession for the last few years:

"London Cyclopaedia of Practical Medicine," article "Puerperal

Fever," 1833.

Mr. Ceeley's Account of the Puerperal Fever at Aylesbury,

"Lancet," 1835.

Dr. Ramsbotham's Lecture, "London Medical Gazette," 1835.

Mr. Yates Ackerly's Letter in the same journal, 1838.

Mr. Ingleby on Epidemic Puerperal Fever, "Edinburgh Medical and

Surgical Journal," 1838.

Mr. Paley's Letter, "London Medical Gazette," 1839.

Remarks at the Medical and Chirurgical Society, "Lancet," 1840.

Dr. Rigby's "System of Midwifery," 1841.

"Nunneley on Erysipelas," a work which contains a large number of

references on the subject, 1841.

"British and Foreign Quarterly Review," 1842.

Dr. S. Jackson, of Northumberland, as already quoted from the

Summary of the College of Physicians, 1842.

And, lastly, a startling series of cases by Mr. Storrs, of

Doncaster, to be found in the "American Journal of the Medical

Sciences" for January, 1843.

The relation of puerperal fever with other continued fevers would

seem to be remote and rarely obvious. Hey refers to two cases of

synochus occurring in the Royal Infirmary of Edinburgh, in women

who had attended upon puerperal patients. Dr. Collins refers to

several instances in which puerperal fever has appeared to

originate from a continued proximity to patients suffering with

typhus. [Footnote: Treatise on Midwifery, p. 228.]

Such occurrences as those just mentioned, though most important

to be remembered and guarded against, hardly attract our notice

in the midst of the gloomy facts by which they are surrounded. Of

these facts, at the risk of fatiguing repetitions, I have

summoned a sufficient number, as I believe, to convince the most

incredulous that every attempt to disguise the truth which

underlies them all is useless.

It is true that some of the historians of the disease, especially

Hulme, Hull, and Leake, in England; Tonnelle, Duges, and

Baudelocque, in France, profess not to have found puerperal fever

contagious. At the most they give us mere negative facts,

worthless against an extent of evidence which now overlaps the

widest range of doubt, and doubles upon itself in the redundancy

of superfluous demonstration. Examined in detail, this and much

of the show of testimony brought up to stare the daylight of

conviction out of countenance, proves to be in a great measure

unmeaning and inapplicable, as might be easily shown were it

necessary. Nor do I feel the necessity of enforcing the

conclusion which arises spontaneously from the facts which have

been enumerated by formally citing the opinions of those grave

authorities who have for the last half-century been sounding the

unwelcome truth it has cost so many lives to establish.

"It is to the British practitioner," says Dr. Rigby, "that we are

indebted for strongly insisting upon this important and dangerous

character of puerperal fever." [Footnote: British and Foreign

Med. Rev. for January, 1842.]

The names of Gordon, John Clarke, Denman, Burns, Young,

[Footnote: Encyc. Britannica, xiii, 467, art., "Medicine."]

Hamilton,[Footnote: Outlines of Midwifery, p. 109.] Haighton,

[Footnote: Oral Lectures, etc.] Good, [Footnote: Study of

Medicine, ii, 195.] Waller, [Footnote: Medical and Physical

Journal, July, 1830.] Blundell, Gooch, Ramsbotham, Douglas,

[Footnote: Dublin Hospital Reports for 1822.] Lee, Ingleby,

Locock, [Footnote: Library of Practical Medicine, I. 373],

Abercrombie [Footnote: Researches on Diseases of the Stomach,

etc. p. 1841], Alison [Footnote: Library of Practical Medicine,

i, 95.], Travers, [Footnote: Further Researches on Constitutional

Irritation, p. 128], Rigby, and Watson [Footnote: London Medical

Gazette, February, 1842] many of whose writings I have already

referred to, may have some influence with those who prefer the

weight of authorities to the simple deductions of their own

reason from the facts aid before them. A few Continental writers

have adopted similar conclusions [Footnote: See British and

Foreign Medical Review, vol. iil, p. 525, and vol. iv, p. 517.

Also Ed. Med. and Surg. Journal for July 1824, and American

Journal of Med. Sciences for January, 1841.] It gives me pleasure

to remember that, while the doctrine has been unceremoniously

discredited in one of the leading journals [Footnote: PIsid. Med.

Journal, vol. xii, p. 364], and made very light of by teachers in

two of the principal medical schools of this country, Dr.

Channing has for many years inculcated, and enforced by examples,

the danger to be apprehended and the precautions to be taken in

the disease under consideration.

I have no wish to express any harsh feeling with regard to the

painful subject which has come before us. If there are any so far

excited by the story of these dreadful events that they ask for

some word of indignant remonstrance to show that science does not

turn the hearts of its followers into ice or stone, let me remind

them that such words have been uttered by those who speak with an

authority I could not claim [Footnote: Dr. Blundell and Dr. Bigby

in the works already cited.] It is as a lesson rather than as a

reproach that I call up the memory of these irreparable errors

and wrongs. No tongue can tell the heart-breaking calamity they

have caused; they have closed the eyes just opened upon a new

world of love and happiness; they have bowed the strength of

manhood into the dust; they have cast the helplessness of infancy

into the stranger's arms, or bequeathed it, with less cruelty,

the death of its dying parent. There is no tone deep enough for

regret, and no voice loud enough for warning. The woman about to

become a mother. or with her new-born infant upon her bosom,

should be the object of trembling care and sympathy wherever she

bears her tender burden or stretches her aching limbs. The very

outcast of the streets has pity upon her sister in degradation

when the seal of promised maternity is impressed upon her. The

remorseless vengeance of the law, brought down upon its victim by

a machinery as sure as destiny, is arrested in its fall at a word

which reveals her transient claim for mercy. The solemn prayer of

the liturgy singles out her sorrows from the multiplied trials of

life, to plead for her in the hour of peril. God forbid that any

member of the profession to which she trusts her life, doubly

precious at that eventful period, should hazard it negligently,

unadvisedly, or selfishly!

There may be some among those whom I address who are disposed to

ask the question, What course are we to follow in relation to

this matter? The facts are before them, and the answer must be

left to their own judgment and conscience. If any should care to

know my own conclusions, they are the following; and in taking

the liberty to state them very freely and broadly, I would ask

the inquirer to examine them as freely in the light of the

evidence which has been laid before him.

1. A physician holding himself in readiness to attend cases of

midwifery should never take any active part in the post-mortem

examination of cases of puerperal fever.

2. If a physician is present at such autopsies, he should use

thorough ablution, change every article of dress, and allow

twenty-four hours or more to elapse before attending to any case

of midwifery. It may be well to extend the same caution to cases

of simple peritonitis.

3. Similar precautions should be taken after the autopsy or

surgical treatment of cases of erysipelas, if the physician is

obliged to unite such offices with his obstetrical duties, which

is in the highest degree inexpedient.

4. On the occurrence of a single case of puerperal fever In his

practice, the physician is bound to consider the next female he

attends in labor, unless some weeks at least have elapsed, as in

danger of being infected by him, and it is his duty to take every

precaution to diminish her risk of disease and death.

5. If within a short period two cases of puerperal fever happen

close to each other, in the practice of the same physician, the

disease not existing or prevailing in the neighborhood, he would

do wisely to relinquish his obstetrical practice for at least one

month, and endeavor to free himself by every available means from

any noxious influence he may carry about with him.

6. The occurrence of three or more closely connected cases, in

the practice of one individual, no others existing in the

neighborhood, and no other sufficient cause being alleged for the

coincidence, is prima facie evidence that he is the vehicle of

contagion.

7. It is the duty of the physician to take every precaution that

the disease shall not be introduced by nurses or other

assistants, by making proper inquiries concerning them, and

giving timely warning of every suspected source of danger.

8. Whatever indulgence may be granted to those who have

heretofore been the ignorant causes of so much misery, the time

has come when the existence of a private pestilence in the sphere

of a single physician should be looked upon, not as a misfortune,

but a crime; and in the knowledge of such occurrences the duties

of the practitioner to his profession should give way to his

paramount obligations to society.

ADDITIONAL REFERENCES AND CASES.

Fifth Annual Report of the Registrar-General of England, 1843,

Appendix. Letter from William Fair, Esq.--Several new series of

cases are given in the letter of Mr. Storrs, contained in the

appendix to this report. Mr. Storrs suggests precautions similar

to those I have laid down, and these precautions are strongly

enforced by Mr. Farr, who is, therefore, obnoxious to the same

criticisms as myself.

Hall and Dexter, in Am. Journal of Med. Sc. for January, 1844.--

Cases of puerperal fever seeming to originate in erysipelas.

Elkington, of Birmingham, in Provincial Med. Journal, cited in

Am. Journ. Med. Sc. for April, 1844.--Six cases in less than a

fortnight, seeming to originate in a case of erysipelas.

West's Reports, in Brit. and For. Med. Review for October, 1845,

and January, 1847.--Affection of the arm, resembling malignant

pustule, after removing the placenta of a patient who died from

puerperal fever. Reference to cases at Wurzburg, as proving

contagion, and to Keiller's cases in the Monthly Journal for

February, 1846, as showing connection of puerperal fever and

erysipelas.

Kneeland.--Contagiousness of Puerperal Fever. Am. Jour. Med. Sc.,

January, 1846. Also, Connection between Puerperal Fever Epidemic

Erysipelas. Ibid., April, 1846.

Robert Storrs.-Contagious Effects of Puerperal Fever on the Male

Subject; or on Persons not Child-bearing. (From Provincial Med.

and Surg. Journal.) Am. Jour. Med. Sc., January, 1846. Numerous

cases. See also Dr. Reid's case in same journal for April, 1846.

Routh's paper in Proc. of Royal Med. Chir. Soc., Am. Jour. Med.

Sc., April, 1849, also in B. and F. Med. Chir. Review, April,

1850.

Hill, of Leuchars.--A Series of Cases Illustrating the Contagious

Nature of Erysipelas and Puerperal Fever, and their Intimate

Pathological Connection. (From Monthly Journal of Med. Sc.) Am.

Jour. Med. Sc., July, 1850.

Skoda on the Causes of Puerperal Fever. (Peritonitis in rabbits,

from inoculation with different morbid secretions.) Am. Jour.

Med. Sc., October, 1850.

Arneth.--Paper read before the National Academy of Medicine.

Annales d'Hygiene, Tome LXV. 2e Partie. ("Means of Disinfection

proposed by M. Semmelweis." Semmelweiss.) Lotions of chloride of

lime and use of nail-brush before admission to lying-in wards,

Alleged sudden and great decrease of mortality from puerperal

fever. Cause of disease attributed to inoculation with cadaveric

matters.) See also Routh's paper, mentioned above.

Moir.--Remarks at a meeting of the Edinburgh Medico-chirurgical

Society. Refers to cases of Dr. Kellie, of Leith. Sixteen in

succession, all fatal. Also to several instances of individual

pupils having had a succession of cases in various quarters of

the town, while others, practising as extensively in the same

localities, had none. Also to several special cases not mentioned

elsewhere. Am. Jour. Med. Sc. for October, 1851. (From New

Monthly Journal of Med. Science.)

Simpson.--Observations at a Meeting of the Edinburgh Obstetrical

Society. (An "eminent gentleman," according to Dr. Meigs, whose

"name is as well known in America as in (his) native land,"

Obstetrics, Phil., 1852, pp. 368, 375.) The student is referred

to this paper for a valuable resume of many of the facts, and the

necessary inferences, relating to this subject. Also for another

series of cases, Mr. Sidey's, five or six in rapid succession.

Dr. Simpson attended the dissection of two of Dr. Sidey's cases,

and freely handled the diseased parts. His next four child-bed

patients were affected with puerperal fever, and it was the first

time he had seen it in practice. As Dr. Simpson is a gentleman

(Dr. Meigs, as above), and as "a gentleman's hands are clean"

(Dr. Meigs' sixth letter), it follows that a gentleman with clean

hands may carry the disease. Am. Jour. Med. Sc., October, 1851.

Peddie.--The five or six cases of Dr. Sidey, followed by the four

of Dr. Simpson, did not end the series. A practitioner in Leith

having examined in Dr. Simpson's house, a portion of the uterus

obtained from one of the patients, had immediately afterwards

three fatal cases of puerperal fever. Dr. Peddie referred to two

distinct series of consecutive cases in his own practice. He had

since taken precautions, and not met with any such cases. Am.

Jour. Med October, 1851.

Copland.--Considers it proved that puerperal fever may be

propagated by the hands and the clothes, or either, of a third

person, the bed-clothes or body-clothes of a patient. Mentions a

new series of cases, one of which he saw, with the practitioner

who had attended them. She was THE SIXTH he had had within a few

days. ALL DIED. Dr. Copland insisted that contagion had caused

these cases; advised precautionary measures, and the practitioner

had no other cases for a considerable time. Considers it

CRIMINAL, after the evidence adduced,--which be could have

quadrupled,--and the weight of authority brought forward, for a

practitioner to be the medium of transmitting contagion and death

to his patients. Dr. Copland lays down rules similar to those

suggested by myself, and is therefore entitled to the same

epithet for so doing. Medical Dictionary, New York, 1853.

Article, Puerperal States and Diseases.

If there is any appetite for facts so craving as to be yet

unappeased,--lassata, necdum satiata,--more can be obtained. Dr.

Hodge remarks that "the frequency and importance of this singular

circumstance that the disease is occasionally more prevalent

with one practitioner than another, has been exceedingly

overrated." More than thirty strings of cases, more than two

hundred and fifty sufferers from puerperal fever, more than one

hundred and thirty deaths, appear as the results of a sparing

estimate of such among the facts I have gleaned as could be

numerically valued. These facts constitute, we may take it for

granted, but a small fraction of those that have actually

occurred. The number of them might be greater, but "'t is enough,

't will serve," in Mercutio's modest phrase, so far as frequency

is concerned. For a just estimate of the importance of the

singular circumstance, it might be proper to consult the languid

survivors, the widowed husbands, and the motherless children, as

well as "the unfortunate accoucheur."

ON THE ANTISEPTIC PRINCIPLE OF THE PRACTICE OF SURGERY

BY

JOSEPH LISTER

INTRODUCTORY NOTE

Joseph Lister was born at Upton, Essex, England, in 1827, and

received Aw general education at the University of London. After

graduation he studied medicine in London and Edinburgh, and

became lecturer in surgery at the University in the latter city.

Later he was professor of surgery at Glasgow, at Edinburgh, and

at King's College Hospital, London, and surgeon to Queen

Victoria. He was made a baronet in 1883; retired from teaching in

1893; and was raised to the peerage in 1897, with the title of

Baron Lister.

Even before the work of Pasteur on fermentation and putrefaction,

Lister had been convinced of the importance of scrupulous

cleanliness and the usefulness of deodorants in the operating

room; and when, through Pasteur's researches, he realised that

the formation of PUS was due to bacteria, he proceeded to develop

his antiseptic surgical methods. The immediate success of the new

treatment led to its general adoption, with results of such

beneficence as to make it rank as one of the great discoveries of

the age.

ON THE ANTISEPTIC PRINCIPLE OF THE PRACTICE OF SURGERY (1867)

In the course of an extended investigation into the nature of

inflammation, and the healthy and morbid conditions of the blood

in relation to it, I arrived several years ago at the conclusion

that the essential cause of suppuration in wounds is

decomposition brought about by the influence of the atmosphere

upon blood or serum retained within them, and, in the case of

contused wounds, upon portions of tissue destroyed by the

violence of the injury.

To prevent the occurrence of suppuration with all its attendant

risks was an object manifestly desirable, but till lately

apparently unattainable, since it seemed hopeless to attempt to

exclude the oxygen which was universally regarded as the agent by

which putrefaction was effected. But when it had been shown by

the researches of Pasteur that the septic properties of the

atmosphere depended not on the oxygen, or any gaseous

constituent, but on minute organisms suspended in it, which owed

their energy to their vitality, it occurred to me that

decomposition in the injured part might be avoided without

excluding the air, by applying as a dressing some material

capable of destroying the life of the floating particles. Upon

this principle I have based a practice of which I will now

attempt to give a short account.

The material which I have employed is carbolic or phenic acid, a

volatile organic compound, which appears to exercise a peculiarly

destructive influence upon low forms of life, and hence is the

most powerful antiseptic with which we are at present acquainted.

The first class of cases to which I applied it was that of

compound fractures, in which the effects of decomposition in the

injured part were especially striking and pernicious. The results

have been such as to establish conclusively the great principle

that all local inflammatory mischief and general febrile

disturbances which follow severe injuries are due to the

irritating and poisonous influence of decomposing blood or

sloughs. For these evils are entirely avoided by the antiseptic

treatment, so that limbs which would otherwise be unhesitatingly

condemned to amputation may be retained, with confidence of the

best results.

In conducting the treatment, the first object must be the

destruction of any septic germs which may have been introduced

into the wounds, either at the moment of the accident or during

the time which has since elapsed. This is done by introducing the

acid of full strength into all accessible recesses of the wound

by means of a piece of rag held in dressing forceps and dipped

into the liquid. [Footnote: The addition of a few drops of water

to a considerable quantity of the acid, induces it to assume

permanently the liquid form.] This I did not venture to do in the

earlier cases; but experience has shown that the compound which

carbolic acid forms with the blood, and also any portions of

tissue killed by its caustic action, including even parts of the

bone, are disposed of by absorption and organisation, provided

they are afterwards kept from decomposing. We are thus enabled to

employ the antiseptic treatment efficiently at a period after the

occurrence of the injury at which it would otherwise probably

fail. Thus I have now under my care, in Glasgow Infirmary, a boy

who was admitted with compound fracture of the leg as late as

eight and one-half hours after the accident, in whom,

nevertheless, all local and constitutional disturbance was

avoided by means of carbolic acid, and the bones were soundly

united five weeks after his admission.

The next object to be kept in view is to guard effectually

against the spreading of decomposition into the wound along the

stream of blood and serum which oozes out during the first few

days after the accident, when the acid originally applied has

been washed out or dissipated by absorption and evaporation. This

part of the treatment has been greatly improved during the past

few weeks. The method which I have hitherto published (see Lancet

for Mar. 16th, 23rd, 30th, and April 27th of the present year)

consisted in the application of a piece of lint dipped in the

acid, overlapping the sound skin to some extent and covered with

a tin cap, which was daily raised in order to touch the surface

of the lint with the antiseptic. This method certainly succeeded

well with wounds of moderate size; and indeed I may say that in

all the many cases of this kind which have been so treated by

myself or my house-surgeons, not a single failure has occurred.

When, however, the wound is very large, the flow of blood and

serum is so profuse, especially during the first twenty-four

hours, that the antiseptic application cannot prevent the spread

of decomposition into the interior unless it overlaps the sound

skin for a very considerable distance, and this was inadmissible

by the method described above, on account of the extensive

sloughing of the surface of the cutis which it would involve.

This difficulty has, however, been overcome by employing a paste

composed of common whiting (carbonate of lime), mixed with a

solution of one part of carbolic acid in four parts of boiled

linseed oil so as to form a firm putty. This application contains

the acid in too dilute a form to excoriate the skin, which it may

be made to cover to any extent that may be thought desirable,

while its substance serves as a reservoir of the antiseptic

material. So long as any discharge continues, the paste should be

changed daily, and, in order to prevent the chance of mischief

occurring during the process, a piece of rag dipped in the

solution of carbolic acid in oil is put on next the skin, and

maintained there permanently, care being taken to avoid raising

it along with the putty. This rag is always kept in an antiseptic

condition from contact with the paste above it, and destroys any

germs which may fall upon it during the short time that should

alone be allowed to pass in the changing of the dressing. The

putty should be in a layer about a quarter of an inch thick, and

may be advantageously applied rolled out between two pieces of

thin calico, which maintain it in the form of a continuous sheet,

which may be wrapped in a moment round the whole circumference of

a limb if this be thought desirable, while the putty is prevented

by the calico from sticking to the rag which is next the

skin.[Footnote: In order to prevent evaporation of the acid,

which passes readily through any organic tissue, such as oiled

silk or gutta percha, it is well to cover the paste with a sheet

of block tin. or tinfoil strengthened with adhesive plaster. The

tin sheet lead used for lining tea chests will also answer the

purpose, and may be obtained from any wholesale grocer.] When all

discharge has ceased, the use of the paste is discontinued, but

the original rag is left adhering to the skin till healing by

scabbing is supposed to be complete. I have at present in the

hospital a man with severe compound fracture of both bones of the

left leg, caused by direct violence, who, after the cessation of

the sanibus discharge under the use of the paste, without a drop

of pus appearing, has been treated for the last two weeks exactly

as if the fracture was a simple one. During this time the rag,

adhering by means of a crust of inspissated blood collected

beneath it, has continued perfectly dry, and it will be left

untouched till the usual period for removing the splints in a

simple fracture, when we may fairly expect to find a sound

cicatrix beneath it. We cannot, however, always calculate on so

perfect a result as this. More or less pus may appear after the

lapse of the first week, and the larger the wound, the more

likely this is to happen. And here I would desire earnestly to

enforce the necessity of persevering with the antiseptic

application in spite of the appearance of suppuration, so long as

other symptoms are favorable. The surgeon is extremely apt to

suppose that any suppuration is an indication that the antiseptic

treatment has failed, and that poulticing or water dressing

should be resorted to. But such a course would in many cases

sacrifice a limb or a life. I cannot, however, expect my

professional brethren to follow my advice blindly in such a

matter, and therefore I feel it necessary to place before them,

as shortly as I can, some pathological principles intimately

connected, not only with the point we are immediately

considering, but with the whole subject of this paper. If a

perfectly healthy granulating sore be well washed and covered

with a plate of clean metal, such as block tin, fitting its

surface pretty accurately, and overlapping the surrounding skin

an inch or so in every direction and retained in position by

adhesive plaster and a bandage, it will be found, on removing it

after twenty-four or forty-eight hours, that little or nothing

that can be called pus is present, merely a little transparent

fluid, while at the same time there is an entire absence of the

unpleasant odour invariably perceived when water dressing is

changed. Here the clean metallic surface presents no recesses

like those of porous lint for the septic germs to develope in,

the fluid exuding from the surface of the granulations has flowed

away undecomposed, and the result is the absence of suppuration.

This simple experiment illustrates the important fact that

granulations have no inherent tendency to form pus, but do so

only when subjected to preternatural stimulus. Further, it shows

that the mere contact of a foreign body does not of itself

stimulate granulations to suppurate; whereas the presence of

decomposing organic matter does. These truths are even more

strikingly exemplified by the fact that I have elsewhere recorded

(Lancet, March 23rd, 1867), that a piece of dead bone free from

decomposition may not only fail to induce the granulations around

it to suppurate, but may actually be absorbed by them; whereas a

bit of dead bone soaked with putrid pus infallibly induces

suppuration in its vicinity.

Another instructive experiment is, to dress a granulating sore

with some of the putty above described, overlapping the sound

skin extensively; when we find, in the course of twenty-four

hours, that pus has been produced by the sore, although the

application has been perfectly antiseptic; and, indeed, the

larger the amount of carbolic acid in the paste, the greater is

the quantity of pus formed, provided we avoid such a proportion

as would act as a caustic. The carbolic acid, though it prevents

decomposition, induces suppuration--obviously by acting as a

chemical stimulus; and we may safely infer that putrescent

organic materials (which we know to be chemically acrid) operate

in the same way.

In so far, then, carbolic acid and decomposing substances are

alike; viz., that they induce suppuration by chemical

stimulation, as distinguished from what may be termed simple

inflammatory suppuration, such as that in which ordinary

abscesses originate--where the pus appears to be formed in

consequence of an excited action of the nerves, independently of

any other stimulus. There is, however, this enormous difference

between the effects of carbolic acid and those of decomposition;

viz., that carbolic acid stimulates only the surface to which it

is at first applied, and every drop of discharge that forms

weakens the stimulant by diluting it; but decomposition is a

self-propagating and self-aggravating poison, and, if it occur at

the surface of a severely injured limb, it will spread into all

its recesses so far as any extravasated blood or shreds of dead

tissue may extend, and lying in those recesses, it will become

from hour to hour more acrid, till it requires the energy of a

caustic sufficient to destroy the vitality of any tissues

naturally weak from inferior vascular supply, or weakened by the

injury they sustained in the accident.

Hence it is easy to understand how, when a wound is very large,

the crust beneath the rag may prove here and there insufficient

to protect the raw surface from the stimulating influence of the

carbolic acid in the putty; and the result will be first the

conversion of the tissues so acted on into granulations, and

subsequently the formation of more or less pus. This, however,

will be merely superficial, and will not interfere with the

absorption and organisation of extravasated blood or dead tissues

in the interior. But, on the other hand, should decomposition set

in before the internal parts have become securely consolidated,

the most disastrous results may ensue.

I left behind me in Glasgow a boy, thirteen years of age, who,

between three and four weeks previously, met with a most severe

injury to the left arm, which he got entangled in a machine at a

fair. There was a wound six inches long and three inches broad,

and the skin was very extensively undermined beyond its limits,

while the soft parts were generally so much lacerated that a pair

of dressing forceps introduced at the wound and pushed directly

inwards appeared beneath the skin at the opposite aspect of the

limb. From this wound several tags of muscle were hanging, and

among them was One consisting of about three inches of the

triceps in almost Its entire thickness; while the lower fragment

of the bone, which was broken high up, was protruding four inches

and a half, stripped of muscle, the skin being tucked in under

it. Without the assistance of the antiseptic treatment, I should

certainly have thought of nothing else but amputation at the

shoulder-joint; but, as the radial pulse could be felt and the

fingers had sensation, I did not hesitate to try to save the limb

and adopted the plan of treatment above described, wrapping the

arm from the shoulder to below the elbow in the antiseptic

application, the whole interior of the wound, together with the

protruding bone, having previously been freely treated with

strong carbolic acid. About the tenth day, the discharge, which

up to that time had been only sanious and serous, showed a slight

admixture of slimy pus; and this increased till (a few days

before I left) it amounted to about three drachms in twenty-four

hours. But the boy continued as he had been after the second day,

free from unfavorable symptoms, with pulse, tongue, appetite, and

sleep natural and strength increasing, while the limb remained as

it had been from the first, free from swelling, redness, or pain.

I. therefore, persevered with the antiseptic dressing; and,

before I left, the discharge was already somewhat less, while the

bone was becoming firm. I think it likely that, in that boy's

case, I should have found merely a superficial sore had I taken

off all the dressings at the end of the three weeks; though,

considering the extent of the injury, I thought it prudent to let

the month expire before disturbing the rag next the skin. But I

feel sure that, if I had resorted to ordinary dressing when the

pus first appeared, the progress of the case would have been

exceedingly different.

The next class of cases to which I have applied the antiseptic

treatment is that of abscesses. Here also the results have been

extremely satisfactory, and in beautiful harmony with the

pathological principles indicated above. The pyogenic membrane,

like the granulations of a sore, which it resembles in nature,

forms pus, not from any inherent disposition to do so, but only

because it is subjected to some preternatural stimulation. In an

ordinary abscess, whether acute or chronic, before it is opened

the stimulus which maintains the suppuration is derived from the

presence of pus pent up within the cavity. When a free opening is

made in the ordinary way, this stimulus is got rid of, but the

atmosphere gaining access to the contents, the potent stimulus of

decomposition comes into operation, and pus is generated in

greater abundance than before. But when the evacuation is

effected on the antiseptic principle, the pyogenic membrane,

freed from the influence of the former stimulus without the

substitution of a new one, ceases to suppurate (like the

granulations of a sore under metallic dressing), furnishing

merely a trifling amount of clear serum, and, whether the opening

be dependent or not, rapidly contracts and coalesces. At the same

time any constitutional symptoms previously occasioned by the

accumulation of the matter are got rid of without the slightest

risk of the irritative fever or hectic hitherto so justly dreaded

in dealing with large abscesses.

In order that the treatment may be satisfactory, the abscess must

be seen before it is opened. Then, except in very rare and

peculiar cases [Footnote: As an instance of one of these

exceptional cases, I may mention that of an abscess in the

vicinity of the colon, and afterwords proved by post-mortem

examination to have once communicated with it. Here the pus was

extremely offensive when evacuated, and exhibited vibros under

the microscope.], there are no septic organisms in the contents,

so that it is needless to introduce carbolic acid into the

interior. Indeed, such a procedure would be objectionable, as it

would stimulate the pyogenic membrane to unnecessary suppuration.

All that is requisite is to guard against the introduction of

living atmospheric germs from without, at the same time that free

opportunity is afforded for the escape of the discharge from

within.

I have so lately given elsewhere a detailed account of the method

by which this is effected (Lancet, July 27th, 1867), that I shall

not enter into it at present further than to say that the means

employed are the same as those described above for the

superficial dressing of compound fractures; viz., a piece of rag

dipped into the solution of carbolic add in oil to serve as an

antiseptic curtain, under cover of which the abscess is evacuated

by free incision, and the antiseptic paste to guard against

decomposition occurring in the stream of pus that flows out

beneath it; the dressing being changed daily until the sinus is

closed.

The most remarkable results of this practice in a pathological

point of view have been afforded by cases where the formation of

pus depended on disease of bone. Here the abscesses, instead of

forming exceptions to the general class in the obstinacy of the

suppuration, have resembled the rest in yielding in a few days

only a trifling discharge, and frequently the production of pus

has ceased from the moment of the evacuation of the original

contents. Hence it appears that caries, when no longer labouring

as heretofore under the irritation of decomposing matter, ceases

to be an opprobrium of surgery, and recovers like other

inflammatory affections. In the publication before alluded to, I

have mentioned the case of a middle-aged man with a psoas abscess

depending in diseased bone, in whom the sinus finally closed

after months of patient perseverance with the antiseptic

treatment. Since that article was written I have had another

instance of abscess equally gratifying, but the differing in the

circumstance that the disease and the recovery were more rapid in

their course. The patient was a blacksmith, who had suffered four

and a half months before I saw him from symptoms of ulceration of

cartilage in the left elbow. These had latterly increased in

severity so as to deprive him entirely of his night's rest and of

appetite. I found the region of the elbow greatly swollen, and on

careful examination found a fluctuating point at the outer aspect

of the articulation. I opened it on the antiseptic principle, the

incision evidently penetrating to the joint, giving exit to a few

drachms of pus. The medical gentleman under whose care he was

(Dr. Macgregor, of Glasgow) supervised the daily dressing with

the carbolic acid paste till the patient went to spend two or

three weeks at the coast, when his wife was entrusted with it.

Just two months after I opened the abscess, he called to show me

the limb, stating that the discharge had been, for at least two

weeks, as little as it was then, a trifling moisture upon the

paste, such as might be accounted for by the little sore caused

by the incision. On applying a probe guarded with an antiseptic

rag, I found that the sinus was soundly closed, while the limb

was free from swelling or tenderness; and, although he had not

attempted to exercise it much, the joint could already be moved

through a considerable angle. Here the antiseptic principle had

effected the restoration of a joint, which, on any other known

system of treatment, must have been excised.

Ordinary contused wounds are, of course, amenable to the same

treatment as compound fractures, which are a complicated variety

of them. I will content myself with mentioning a single instance

of this class of cases. In April last, a volunteer was

discharging a rifle when it burst, and blew back the thumb with

its metacarpal bone, so that it could be bent back as on a hinge

at the trapezial joint, which had evidently been opened, while

all the soft parts between the metacarpal bones of the thumb and

forefinger were torn through. I need not insist before my present

audience on the ugly character of such an injury. My house-

surgeon, Mr. Hector Cameron, applied carbolic acid to the whole

raw surface, and completed the dressing as if for compound

fracture. The hand remained free from pain, redness or swelling,

and with the exception of a shallow groove, all the wound

consolidated without a drop of matter, so that if it had been a

clean cut, it would have been regarded as a good example of

primary union. The small granulating surface soon healed, and at

present a linear cicatrix alone tells of the injury he has

sustained, while his thumb has all its movements and his hand a

fine grasp.

If the severest forms of contused and lacerated wounds heal thus

kindly under the antiseptic treatment, it is obvious that its

application to simple incised wounds must be merely a matter of

detail. I have devoted a good deal of attention to this class,

but I have not as yet pleased myself altogether with any of the

methods I have employed. I am, however, prepared to go so far as

to say that a solution of carbolic acid in twenty parts of water,

while a mild and cleanly application, may be relied on for

destroying any septic germs that may fall upon the wound during

the performance of an operation; and also that, for preventing

the subsequent introduction of others, the paste above described,

applied as for compound fractures, gives excellent results. Thus

I have had a case of strangulated inguinal hernia in which it was

necessary to take away half a pound of thickened omentum, heal

without any deep-seated suppuration or any tenderness of the sac

or any fever; and amputations, including one immediately below

the knee, have remained absolutely free from constitutional

symptoms.

Further, I have found that when the antiseptic treatment is

efficiently conducted, ligatures may be safely cut short and left

to be disposed of by absorption or otherwise. Should this

particular branch of the subject yield all that it promises,

should it turn out on further trial that when the knot is applied

on the antiseptic principle, we may calculate as securely as if

it were absent on the occurrence of healing without any deep-

seated suppuration, the deligation of main arteries in their

continuity will be deprived of the two dangers that now attend

it, viz., those of secondary haemorrhage and an unhealthy state

of the wound. Further, it seems not unlikely that the present

objection to tying an artery in the immediate vicinity of a large

branch may be done away with; and that even the innominate, which

has lately been the subject of an ingenious experiment by one of

the Dublin surgeons, on account of its well-known fatality under

the ligature for secondary haemorrhage, may cease to have this

unhappy character when the tissues in the vicinity of the thread,

instead of becoming softened through the influence of an

irritating decomposing substance, are left at liberty to

consolidate firmly near an unoffending though foreign body.

It would carry me far beyond the limited time which, by the rules

of the Association, is alone at my disposal, were I to enter into

the various applications of the antiseptic principle in the

several special departments of surgery.

There is, however, one point more that I cannot but advert to,

viz., the influence of this mode of treatment upon the general

healthiness of an hospital. Previously to its introduction the

two large wards in which most of my cases of accident and of

operation are treated were among the unhealthiest in the whole

surgical division of the Glasgow Royal Infirmary, in consequence

apparently of those wards being unfavorably placed with reference

to the supply of fresh air; and I have felt ashamed when

recording the results of my practice, to have so often to allude

to hospital gangrene or pyaemia. It was interesting, though

melancholy, to observe that whenever all or nearly all the beds

contained cases with open sores, these grievous complications

were pretty sure to show themselves; so that I came to welcome

simple fractures, though in themselves of little interest either

for myself or the students, because their presence diminished the

proportion of open sores among the patients. But since the

antiseptic treatment has been brought into full operation, and

wounds and abscesses no longer poison the atmosphere with putrid

exhalations, my wards, though in other respects under precisely

the same circumstances as before, have completely changed their

character; so that during the last nine months not a single

instance of pysemia, hospital gangrene, or erysipelas has

occurred in them.

As there appears to be no doubt regarding the cause of this

change, the importance of the fact can hardly be exaggerated.

THE PHYSIOLOGICAL THEORY OF FERMENTATION

BY LOUIS PASTEUR

TRANSLATED BY

F. FAULKNER AND D. C. ROBB

AND REVISED

THE GERM THEORY AND ITS APPLICATIONS TO MEDICINE AND SURGERY

BY MM. PASTEUR, JOURBERT, AND CHAMBERLAND

TRANSLATED BY

H. C. ERNST, M. D.

PROFESSOR OF BACTERIOLOGY IN THE HARVARD MEDICAL SCHOOL

ON THE EXTENSION OF THE GERM THEORY TO THE ETIOLOGY OF CERTAIN

COMMON DISEASES

BY LOUIS PASTEUR

TRANSLATED BY H. C. ERNST, M. D.

INTRODUCTORY NOTE

Louis Pasteur was born at Dole, Jura, France, December 27, 1822,

and died near Saint-Cloud, September 28, 1895. His interest in

science, and especially in chemistry, developed early, and by the

time he was twenty-six he was professor of the physical sciences

at Dijon. The most important academic positions held by him later

were those as professor of chemistry at Strasburg, 1849; dean of

the Faculty of Sciences at Lille, 1854; science director of the

Ecole Normale Superieure, Paris, 1857; professor of geology,

physics, and chemistry at the Ecole des Beaux Arts; Professor of

chemistry at the Sorbonne, 1867. After 1875 he carried on his

researches at the Pasteur Institute. He was a member of the

Institute, and received many honors from learned societies at

home and abroad.

In respect of the number and importance, practical as well as

scientific, of his discoveries, Pasteur has hardly a rival in the

history of science. He may be regarded as the founder of modern

stereo-chemistry; and his discovery that living organisms are the

cause of fermentation is the basis of the whole modern germ-

theory of disease and of the antiseptic method of treatment. His

investigations of the diseases of beer and wine; of pebrine, a

disease affecting silk-worms; of anthrax, and of fowl cholera,

were of immense commercial importance and led to conclusions

which have revolutionised physiology, pathology, and

therapeutics. By his studies in the culture of bacteria of

attenuated virulence he extended widely the practise of

inoculation with a milder form of various diseases, with a view

to producing immunity.

The following papers present some of the most important of his

contributions, and exemplify his extraordinary powers of lucid

exposition and argument.

TO THE MEMORY OF MY FATHER

FORMERLY A SOLDIER UNDER THE FIRST EMPIRE CHEVALIER OF THE LEGION

OF HONOR

The longer I live, the better I understand the kindness of thy

heart and the high quality of thy mind.

The efforts which I have devoted to these Studies, as well as

those which preceded them, are the fruit of thy counsel and

example.

Desiring to honor these filial remembrances, I dedicate this work

to thy memory.

L. PASTEUR.

AUTHOR'S PREFACE

Our misfortunes inspired me with the idea of these researches. I

undertook them immediately after the war of 1870, and have since

continued them without interruption, with the determination of

perfecting them, and thereby benefiting a branch of industry

wherein we are undoubtedly surpassed by Germany.

I am convinced that I have found a precise, practical solution of

the arduous problem which I proposed to myself--that of a process

of manufacture, independent of season and locality, which should

obviate the necessity of having recourse to the costly methods of

cooling employed in existing processes, and at the same time

secure the preservation of its products for any length of time.

These new studies are based on the same principles which guided

me in my researches on wine, vinegar, and the silkworm disease--

principles, the applications of which are practically unlimited.

The etiology of contagious diseases may, perhaps, receive from

them an unexpected light.

I need not hazard any prediction concerning the advantages likely

to accrue to the brewing industry from the adoption of such a

process of brewing as my study of the subject has enabled me to

devise, and from an application of the novel facts upon which

this process is founded. Time is the best appraiser of scientific

work, and I am not unaware that an industrial discovery rarely

produces all its fruit in the hands of its first inventor.

I began my researches at Clermont-Ferrand, in the laboratory, and

with the help, of my friend M. Duclaux, professor of chemistry at

the Faculty of Sciences of that town. I continued them in Paris,

and afterwards at the great brewery of Tourtel Brothers, of

Tantonville, which is admitted to be the first in France. I

heartily thank these gentlemen for their extreme kindness. I owe

also a public tribute of gratitude to M. Kuhn, a skillful brewer

of Chamalieres, near Clermont-Ferrand, as well as to M. Velten of

Marseilles, and to MM. de Tassigny, of Reims, who have placed at

my disposal their establishments and their products, with the

most praiseworthy eagerness.

L. PASTEUR.

Paris, June 1, 1879.

THE PHYSIOLOGICAL THEORY OF FERMENTATION

I. ON THE RELATIONS EXISTING BETWEEN OXYGEN AND YEAST

It is characteristic of science to reduce incessantly the number

of unexplained phenomena. It is observed, for instance, that

fleshy fruits are not liable to fermentation so long as their

epidermis remains uninjured. On the other hand, they ferment very

readily when they are piled up in heaps more or less open, and

immersed in their saccharine juice. The mass becomes heated and

swells; carbonic acid gas is disengaged, and the sugar disappears

and is replaced by alcohol. Now, as to the question of the origin

of these spontaneous phenomena, so remarkable in character as

well as usefulness for man's service, modern knowledge has taught

us that fermentation is the consequence of a development of

vegetable cells the germs of which do not exist in the saccharine

juices within fruits; that many varieties of these cellular

plants exist, each giving rise to its own particular

fermentation. The principal products of these various

fermentations, although resembling each other in their nature,

differ in their relative proportions and in the accessory

substances that accompany them, a fact which alone is sufficient

to account for wide differences in the quality and commercial

value of alcoholic beverages.

Now that the discovery of ferments and their living nature, and

our knowledge of their origin, may have solved the mystery of the

spontaneous appearance of fermentations in natural saccharine

juices, we may ask whether we must still regard the reactions

that occur in these fermentations as phenomena inexplicable by

the ordinary laws of chemistry. We can readily see that

fermentations occupy a special place in the series of chemical

and biological phenomena. What gives to fermentations certain

exceptional characters of which we are only now beginning to

suspect the causes, is the mode of life in the minute plants

designated under the generic name of ferments, a mode of life

which is essentially different from that in other vegetables, and

from which result phenomena equally exceptional throughout the

whole range of the chemistry of living beings.

The least reflection will suffice to convince us that the

alcoholic ferments must possess the faculty of vegetating and

performing their functions out of contact with air. Let us

consider, for instance, the method of vintage practised in the

Jura. The bunches are laid at the foot of the vine in a large

tub, and the grapes there stripped from them. When the grapes,

some of which are uninjured, others bruised, and all moistened by

the juice issuing from the latter, fill the tub--where they form

what is called the vintage--they are conveyed in barrels to large

vessels fixed in cellars of a considerable depth. These vessels

are not filled to more than three-quarters of their capacity.

Fermentation soon takes place in them, and the carbonic acid gas

finds escape through the bunghole, the diameter of which, in the

case of the largest vessels, is not more than ten or twelve

centimetres (about four inches). The wine is not drawn off before

the end of two or three months. In this way it seems highly

probable that the yeast which produces the wine under such

conditions must have developed, to a great extent at least, out

of contact with oxygen. No doubt oxygen is not entirely absent

from the first; nay, its limited presence is even a necessity to

the manifestation of the phenomena which follow. The grapes are

stripped from the bunch in contact with air, and the must which

drops from the wounded fruit takes a little of this gas into

solution. This small quantity of air so introduced into the must,

at the commencement of operations, plays a most indispensable

part, it being from the presence of this that the spores of

ferments which are spread over the surface of the grapes and the

woody part of the bunches derive the power of starting their

vital phenomena [Footnote: It has been marked in practice that

fermentation is facilitated by leaving the grapes on the bunches.

The reason of this has not yet been discovered. Still we have no

doubt that it may be attributed, principally, to the fact that

the interatices between the grapes, and the spaces between the

bunch leaves throughout, considerably increase the volume of air

placed at the service of the germs of ferment.]. This air,

however, especially when the grapes have been stripped from the

bunches, is in such small proportion, and that which is in

contact with the liquid mass is so promptly expelled by the

carbonic acid gas, which is evolved as soon as a little yeast has

formed, that it will readily be admitted that most of the yeast

is produced apart from the influence of oxygen, whether free or

in solution. We shall revert to this fact, which is of great

importance. At present we are only concerned in pointing out

that, from the mere knowledge of the practices of certain

localities, we are induced to believe that the cells of yeast,

after they have developed from their spores, continue to live and

multiply without the intervention of oxygen, and that the

alcoholic ferments have a mode of life which is probably quite

exceptional, since it is not generally met with in other species,

vegetable or animal.